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Wiki Determining E/M Level

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wverret

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Good afternoon,
I have a provider record that indicates the patient is a new patient here for follow up care for a surgical procedure. In reviewing the documentation, the provider indicates that the individual needs to have a dtap. would you give this provider a point for ordering something from the medicine section?

Thanks
Willie
 
Is the provider documenting the vaccination as given in the clinic? Then get the administration and the HCPCS code for the vaccine. I would not give a data point for recommending that the vaccination be given.
 
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